Lay perceptions of diabetes mellitus and prevention costs and benefits among adults undiagnosed with the condition in Singapore: A qualitative study

Therapeutic lifestyle changes can reduce individual risk of type 2 diabetes (T2D) by up to 58%. In Singapore, rates of preventive practices were low, despite a high level of knowledge and awareness of T2D risk and prevention.

Lay perceptions of diabetes mellitus

and prevention costs and benefits among adults undiagnosed with the condition in Singapore:

a qualitative study

Jumana Hashim1, Helen Elizabeth Smith2, E Shyong Tai3 and Huso Yi1*

Abstract

Background: Therapeutic lifestyle changes can reduce individual risk of type 2 diabetes (T2D) by up to 58% In

Singapore, rates of preventive practices were low, despite a high level of knowledge and awareness of T2D risk and prevention The study explored the context of the discrepancy between knowledge and practices in T2D prevention among adults undiagnosed with the condition

Methods: In-depth interviews with 41 adults explored lay beliefs of T2D and the sources of these perceptions,

subjective interpretation of how T2D may impact lives, and perceived costs and benefits of practising preventative behaviours Purposive sampling was used to maximise the variability of participants in demographic characteristics Thematic analysis was conducted to identify themes related to the domains of inquiry

Results: Participants’ risk perceptions were influenced by familial, social, and cultural contexts of the

representa-tion and management of T2D condirepresenta-tions The adverse effects of T2D were often narrated in food culture The cost of adopting a healthy diet was perceived at a high cost of life pleasure derived from food consumption and social inter-actions Inconveniences, loss of social functions, dependency and distress were the themes related to T2D manage-ment Participants’ motivation to preventive practices, such as exercise and weight loss, were influenced by short-term observable benefits

Conclusions: T2D risk communication needs to be addressed in emotionally impactful and interpersonally salient

ways to increase the urgency to adopt preventative behaviours Shifting perceived benefits from long-term disease prevention to short-term observable wellbeing could reduce the response cost of healthy eating

Keywords: Risk perception, Health communication, Type 2 diabetes, Qualitative study, Singapore

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Introduction

Globally, 1 in 11 adults live with diabetes, and 10% of health expenditure is spent on treating individuals with diabetes [1] Complications from type 2 diabetes (T2D) like renal, ocular, cardiovascular disease, and lower extremity amputations can lead to premature death and loss of productivity among the working-age popula-tion In Singapore, the prevalence of T2D is projected to

be 15% overall and about 40% of those over 60 years in

Open Access

*Correspondence: ephyh@nus.edu.sg

1 Saw Swee Hock School of Public Health, National University of Singapore,

and National University Health System, Singapore, Singapore

Full list of author information is available at the end of the article

2050 [2] The economic burden is expected to increase to

SG$ 2.5 billion by 2050 [3] However, about 80% of T2D

incidences can be prevented by reducing modifiable risk

factors with lifestyle changes [4] Preventive behaviours,

including weight management, physical activity, and

healthy eating can reduce one’s risk for diabetes by up to

58% [5–7]

Since the Ministry of Health in Singapore declared a

“War on Diabetes” in 2016, the Health Promotion Board

(HPB) launched a myriad of prevention efforts like the

‘National Steps Challenge’ to increase physical activity

and ‘National Diabetes Reference Materials’ to

dissemi-nate information on risk management [8] While these

efforts may have increased awareness and knowledge,

practice of preventative behaviours is still suboptimal

Nationally, 81% had adequate functional health literacy

regarding diabetes [9] However, the 2020 national

popu-lation health survey found an increase in obesity

preva-lence across all age groups compared to 2017 [10] A

household survey in 2019 found that 86% and 89% of

par-ticipants agreed that healthy eating and exercise

respec-tively, can control the risk of diabetes However, only 37%

ate the recommended 5 servings of fruits and vegetables,

and 28% met HPB’s physical activity recommendation of

150 min/week [11] To reach higher engagement in T2D

prevention, the discrepancy between knowledge and

practice needs to be addressed

In addition to knowledge, contextual and individual

barriers can influence behaviour While accessibility

chal-lenges due to logistical or financial reasons and

psycho-logical barriers due to limited perceived benefit or threat

were identified to influence T2D prevention across 12

studies globally, the expressed reasons were diverse,

com-plex, and context-specific [12] The influence of culture

and social environment on the likelihood of

undertak-ing preventative measures highlights the importance of

understanding subjective experiences and values Lay

beliefs are the subjective and informal ways

individu-als contextualise their actions, affecting motivation to

adopt healthy and preventative behaviours [13]

Under-standing lay beliefs and risk perceptions in context would

help explain why knowledge does not translate into

prac-tice and identify intervention focal points to increase

the effectiveness of current T2D prevention efforts In

this study, we qualitatively explored the lay beliefs and

risk perceptions of T2D, and attitudes towards

preven-tive behaviours among adults undiagnosed with the

condition

Methods

Participants and procedure

The study population was adults aged between 30 and

60  years without a diagnosis of T2D Our sampling

strategy ensured the diversity of the ethnic groups as T2D was more prevalent among people with Malay and Indian background than Chinese background [2]

A study invitation was posted on bulletin boards in pri-mary care clinics and circulated through email and social media like Facebook During the screening of eligibility,

we collected age, ethnicity, education level, and housing

to ensure our recruited participant sample represented the Singapore population by demographic We had an overwhelming interest from Chinese participants and a few Malay and Indian participants To address this, we encouraged recruited participants to circulate the poster

to their Malay and Indian friends Interviews were con-ducted on a video conference call or in-person and in English, Mandarin, Malay, or Tamil We employed sev-eral approaches to ensure the consistency of data collec-tion in Chinese, Malay, and Tamil We made an interview protocol describing the details of interview data collec-tion: preparation, informed consent, introduction, a topic guide with probing questions (see supplementary file), debriefing, and rules of translation and transcription Researchers who conducted the interviews in Mandarin, Malay, and Tamil were appropriately briefed by the first author (JH), who conducted majority of the other inter-views in English JH has training in behavioural science and qualitative research Additionally, 2 of the 3 of these researchers were current PhD candidates with focus on qualitative research The third researcher went through

an extensive training and several practice rounds with JH before they independently conducted the interviews Interviews lasted from 40 to 70 min Participants were provided with a voucher of SG$30 for compensation for their time With 41 participants, our interviews had reached theoretical and thematic saturation Theoretical and thematic saturation was determined using a hybrid and an iterative process using three criteria, as dis-cussed by JH and the last author (HY), who is an expert

in qualitative research and health psychology: (1) holis-tic understanding of each emergent theme to illustrate them appropriately, (2) three consecutive transcripts with

no new themes found and (3) sufficiently diverse range

of perspective, when our study sample relatively repre-sented the Singapore population [14–16] The study was approved by the university research ethics committee All methods were performed in accordance with the ethics committee’s guidelines and regulations and the Declara-tion of Helsinki

Interview guide

We sought to identify the social and cultural attributes that participants considered when thinking about T2D and how they may contribute in weighing the ‘cost’ and

‘benefit’ of engaging in T2D prevention An interview

topic guide was developed based on the literature review

on knowledge, attitudes, and practice of T2D

preven-tion with a focus on three major domains: (1) lay beliefs

of T2D and the sources of these perceptions; (2)

subjec-tive interpretation of how individuals thought T2D might

impact their lives; and (3) perceived costs and benefits of

practising preventative behaviours The interview topic

guide is provided as supplementary material

Analysis

Interviews were audio-recorded, translated for

non-English interviews, transcribed verbatim, and entered

in NVivo 12 Non-English interviews were read by JH

and HY after transcription to ensure there was

consist-ency in data collection across the different researchers

before entered into the software The six-phase

reflex-ive thematic approach was used for analysis [17] JH

and HY read the transcripts while interviewing to

famil-iarise the data and revise probes if necessary After the

first 10 interviews, JH and HY worked independently

before discussing the preliminary codes and

generat-ing initial themes The initial code scheme was applied

to the remaining interviews using a constant

compari-son method to refine and finalise the codebook This

also allowed us to assess theoretical and thematic

satu-ration We addressed reflexivity throughout the phase of

data collection and interpretation to check any influence

of preconceptions and ensure that significant findings

were not left out or misinterpreted The interviewers had

regular meetings for debriefing and checking whether

personal attributes, qualifications, experiences, and

val-ues affect interviewing and leading interview qval-uestions

The second author (HES) is an expert in primary care

and community engagement; the third author (TES) is

an endocrinologist and an expert in diabetes prevention,

especially in Singapore All had regular meetings where

the first author presented preliminary data analysis, and

all discussed and finalised data interpretation To ensure

the credibility of the analysis, a subset of the participants

(n = 8) was invited to a workshop to discuss the findings

as a form of member-checking They were selected based

on the following criteria: (1) participants had consented

to re-contact during informed consent, and (2)

partici-pants were available for a focus group discussion, which

allowed the participants to freely talk among themselves

as we took overall notes This was not part of the data

collection; therefore, we did not record or transcribe

their discussions No major change was made as the

con-sensus was positive and in agreement with the themes we

identified We reviewed their comments after member

checking to iterate and strengthen our themes and the

narrative to weave them together

Results

Table 1 shows the demographic characteristics of 41 par-ticipants There were 24 females and 17 males, with 16 participants in their 30 s, 14 in their 40 s, and 11 in their

50 s Ethnic distribution followed 61%, 15%, and 20% for Chinese, Malay, and Indian, respectively

Table 2 presents a hierarchal thematic scheme of the novel findings We identified 5 main themes, each with

3 sub-themes: (i) perceptions of diabetes, (ii) sources of perceptions, (iii) relational identity between food and T2D, (iv) perceived losses from healthy eating in T2D, and (v) perceived gains from physical activity in T2D Even though the findings are categorized by the domains

of inquiry, all the sub-themes are interrelated and create the narrative of the given context

Perceptions of diabetes

All the participants were aware of diabetes with a good understanding of its risk factors, like obesity, family his-tory, dietary habits, and sedentary lifestyle Commonly cited symptoms included increased thirst, frequent urination, changes in weight, and “sweet pee which attracted ants.” A few responded there would be no visual

Table 1 Characteristics of Participants

HDB Housing Development Board; Singapore’s public housing scheme

Study Participants

(N = 41)

Singapore Pop

Age

Gender

Ethnicity

Education ≤ Secondary School 13 32% 40%

Housing ≤ 3-room HDB flat 11 27% 24%

4- to 5-room HDB flat 23 56% 55%

Condominium or Maisonette 5 12% 16%

symptoms until a blood test has been taken Participants

also had a good understanding of the disease progression

Apart from the cost of treatment, the initial stages of the

disease management were perceived as “inconvenient”

due to the daily medications and diet considerations

If I had it, I had to take medications regularly and

properly I had to bring medications with me It’s

inconvenient If I were to be in a social setting, I’d

be like, “Oh, I’m sorry, I can’t eat this or drink that”

or like “I need to take my medication.” Then,

peo-ple would look at me weirdly I’d be like, “Should I

explain or not?” (30s, F, Chinese)

Later stages of T2D were perceived as “disastrous

to quality life” due to the complications arising from

T2D Many participants were concerned that they may

become a burden and be unable to care for others

Com-plications of T2D were associated with disabilities that

could cause “(loss of) ability to work, (and) ability to live

independently.”

There is a risk of complications like having kidney

problems, amputations, or maybe even blindness,

or losing your sensitivity, your extremities These

are the complications that someone with diabetes

will have to anticipate But if I develop

complica-tions that result in me developing blindness or limb

amputation, that one will be quite disastrous to the

quality of my life (30s, M, Chinese)

However, most participants expressed that the devel-opment of these complications would be far away, and the progression from the initial stage to complications would be slow They believed such a slower progression

of diabetes compared to other diseases meant that it was not as life-threatening and that diabetic patients have an opportunity to control and manage diabetes with medi-cation and lifestyle adjustment

You may have diabetes, but it may not happen like a one-shot For diabetes, first, you have medication to manage it You have time for treatment You still can control in a way You can try to minimise potential injuries It will not get fatal as compared to heart disease where it strikes up, the recovery time and saving the person is very acute (30s, M, Chinese)

Sources of perceptions

Participants said they actively seek “expert” knowledge only after specific triggers like health screening results

or hearing about T2D diagnosis from their social cir-cles Some participants found the amount of information and use of jargon overwhelming, and the information on actionable steps sometimes contradicting

I usually inquire into a condition when somebody

I know is diagnosed with the condition It usually takes a few searches to understand because there are many sources, which tend to be overly clinical in

Table 2 Hierarchical Thematic Scheme

QoL: Quality of Life, T2D: Type 2 Diabetes

Lay beliefs of T2D

Perceptions of diabetes Initial stages of T2D create inconvenience to lifestyle

Complications from T2D can impact QoL Progression of diabetes is slow Source of perceptions Expert knowledge has limited influence

Influence of the media’s portrayal of characters with diabetes Personal encounters with people living with T2D

Subjective interpretation of how T2D impact lives

Relational identity between food and T2D Perceived susceptibility directly correlated to sugary food intake

Restriction of diet in relation to Singapore’s food culture Convenience and cost of unhealthy vs healthy food

Practicing preventative behaviours

Perceived losses from healthy eating in T2D prevention Interaction with food during gatherings and celebrations

Pleasure derived from food consumption Influence of food on social identity Perceived gains from physical activity in T2D prevention Exercise desirable despite challenges

Immediate observable benefits of exercise Self-improvement by tracking progress

their jargon, which is not very helpful and only

tar-geted to medical professionals Usually, the

contra-dictions are not in the diagnosis but understanding

if it is major or minor, or if any meaningful action

should be taken (50s, M, Chinese)

Hence, many lay perceptions were influenced by the

media portrayal of diabetic patients Participants

recol-lected that the characters with diabetes in the media were

often in the later stages with limb amputations, which

were somewhat disturbing However, diabetes was rarely

reported as a cause of death, even if it was an underlying

health condition

To me, diabetes is a bit far away We hear about

stroke and heart attacks when the media reports

that ‘somebody collapsed while jogging’ Whereas,

when somebody dies from diabetes, we don’t usually

read it in the papers You might die of heart attack

with a pre-existing condition of diabetes But

peo-ple just report your heart attack Diabetes tends to

be at the back of everybody’s mind It exists, but the

media doesn’t put it in the spotlight that often (30s,

M, Chinese)

For participants who had family, relatives, or friends

with T2D, their perceptions of the disease – cause, risk,

and consequence of diabetes – were influenced by what

they observed and heard from the patients In

particu-lar, participants who had parents and relatives with late

stage-associated conditions, their descriptions about the

impact of T2D on life were specific and vivid

She suddenly started to bleed very badly after just

gently scratching a black spot, but she didn’t feel any

pain She passed out at home because of the excess

bleeding We had to call the ambulance, and she had

to go for another operation for her leg When you

have diabetes, it will take longer for the wounds to

be healed, so it took her a long time to heal This is a

real problem (40s, F, Indian)

Relational identity between food and T2D

Common factors influencing perceived risk among

par-ticipants were poor health screening results, obesity,

pos-itive family history, and unhealthy practices, especially

around dietary choices Many participants perceived that

having too much sugar was the main cause of diabetes,

which translated to reduced perceived susceptibility of

T2D among those who did not have many sugary foods

I think my risk is very low I am someone who is not

into sugar - I don’t drink bubble tea, I don’t have a

lot of sweets, biscuits or cakes or chocolates I don’t

have that kind of craving (40s, F, Chinese)

Several participants said when friends and families speak about diabetes, it is usually candidly referring to having too many sweet food items However, the collo-quial reference to sweet foods and sugar as the cause of diabetes did not reduce the consumption of these foods

When you have a gathering, you look at the amount

of food and sugar Then, you casually say like ‘this

is going to get me diabetes.’ But it’s a form of a joke than anything serious (40s, M, Malay)

Participants were asked to share how they thought their lives could be impacted if they were to be diagnosed with T2D A common perceived loss was related to the restriction of diet to manage T2D

If I had diabetes, I would have to have a more restrictive lifestyle I would not be able to eat as much of the food that I enjoy – snacking, eating ice cream and things like this I myself have sweet tooth For me having to be a bit more restrictive would be quite a downer (30s, M, Chinese)

Many participants shared that the diet restriction was particularly impactful in Singapore as the local food cul-ture is important in shaping the Singaporean identity With the variety of food, there were expectations of hav-ing a certain level of culinary experience durhav-ing social gatherings

Given that we are Singaporeans, we love to eat It is difficult to maintain a healthy lifestyle or a healthy diet Our culture is about eating – we have a fusion

of food and all kinds of foods from all around the world Even if healthier, people do not want to meet friends over a fruit platter They will meet for a Korean barbeque So, from a cultural perspective, it’s very hard to disconnect from food (30, M, Chinese)

Participants defined good food as tasty and cheap and shared that people are willing to travel significant dis-tances in search of good food Singaporeans take pride in finding food that has the best value for money, and this pursuit is often a topic of conversation among friends and family

I think it is difficult for people to control their diet Singaporeans like to travel around to find food to eat They might be living in [a neighbourhood in the east], but they do not mind travelling to [a neigh-bourhood in the west] They want the best food that they can get for the three dollars fifty cents They will talk to each other about where to go and what to eat They enjoy eating so much and want total value for money in getting the best bang for their buck (40s,

M, Indian)

Participants pointed out the convenience, ease of

access, and budget-friendly options; ‘hawker centres’

located within every public housing estate providing

diverse local cuisines quickly and cheaply Furthermore,

in recent years’ options of delivery service and the

avail-ability of all types of cuisine, one can access cheaper and

more delicious food any time, from the comfort of home

When you are craving something, or you want to eat

something, usually I must travel all the way there

But now everything is a lot easier to eat something,

and it will come to your doorstep Even if I am tired

or it is late at night, and I feel like having ice cream,

there is [food delivery platform] So, there are a

lot more opportunities to indulge in these kinds of

things (30s, F, Chinese)

Conversely, many participants pointed out that healthy

food options are more expensive and can take a long time

to prepare

In Singapore, the faster and cheaper options are

unhealthy So, if you want to prepare healthy food,

and you have working hours, you need to make a lot

of sacrifices – like wake up early or prepare it the

night before And the ingredients for healthy meals

are not cheap (40s, F, Malay)

Perceived losses from healthy eating in T2D prevention

When speaking of restrictive diet and healthy eating,

par-ticipants alluded to a ‘loss’ in their lifestyle due to reduced

enjoyment and impaired social interactions associated

with food Social relationships and celebrations are

cen-tred on food, and declining food or refusing to eat could

be interpreted as an insult to the host This was

men-tioned by participants across all the ethnic groups

You’re stopping me from eating my favourite food,

you know? I rather die What makes it really hard

is that any form of Chinese celebration has got to do

with food The bigger the celebration, the more food

we have It’s like, if you don’t eat, you’re extremely

rude – it’s insulting not to eat something that is

placed before you (50s, M, Chinese)

Many participants also shared that eating provided a

source of enjoyment and that some participants turned

to food when they were upset or stressed While some

participants shared that they exercise to de-stress, some

participants shared that they eat to de-stress A

partici-pant mentioned the endorphins released when

exercis-ing, while another said the same but when indulging in

delicious food While there was awareness for the need

to mitigate the effects of unhealthy eating, it came in the

form of compromising other meals instead of giving up the pleasure derived from unhealthy foods

The only thing that I’m doing now to control my eat-ing is tryeat-ing not to have breakfast in the morneat-ing I will just try to have lunch and dinner, but it is usu-ally not controlled I should stop eating less fried food But I don’t think I can give up fried chicken that easily It’s just really too good to give up (30, M, Chinese)

Similarly, some participants expressed that they justify their eating habits by having ‘earned their calories’ after exercising and consider their indulgence as a reward The influence of social media culture was also reported, where people post pictures of the aesthetics of the set-ting and the food Participants shared that social identity

is associated with food and enjoying life, and rarely with healthy eating in the context

People eat to survive But for me, I live to eat because

I love to eat So, if I’m not happy, I need to eat to

be happy I love food To continue eating unhealthy food, I compensate for it by doing more exercise So,

I had the calories burned to eat If I don’t exercise and eat, I’ll get fat or something like that But if I exercise and eat, it can balance out, right? Nowa-days, people post their food on social media Wow, they’re so yummy! But, if you burn a fish at home, you wouldn’t post on social media You will only post nice and presentable ones (40s, F, Chinese)

Perceived gains from physical activity in T2D prevention

Demanding work environments and familial responsibili-ties created multiple competing prioriresponsibili-ties even though exercise is desirable These responsibilities often lead to sacrificing sleep, poor eating habits, and exercise time to meet these expectations Participants shared that Singa-pore’s competitive work environment creates high-stress situations There is an expectation to constantly improve skills and qualifications to ensure job security

Stress is one contributing factor People tend to eat more and badly when they have stress People want

to have job security Now there is digital disruption,

so you can become invalid, which is quite scary So,

we need to upgrade ourselves I have attended many courses, and I will attend more, so there is no time to exercise sometimes even though I want to (40s, M, Others)

Participants, especially mothers, shared that time for themselves when they could exercise is seen as a “luxury”

or “culturally challenging” A Muslim woman shared how she felt different and watched when running with a hijab,

a head covering worn by many Muslim women

Inter-nalised expectations of clothing worn during exercise

contrasted with wearing a hijab, creating potential

psy-chological barriers

I’m making a conscious effort, but it is really tough

for me to find a time with kids, work, and

every-thing Most of the days, as a working mom, I seldom

get time for myself to do what I want You feel good

about yourself with those endorphins It is very good

to mentally detox by getting away from home and

kids But, when I ran in the park, I used to feel a bit

shy and embarrassed because I was wearing hijab,

and then I felt like everyone was looking at me (30s,

F, Indian)

Despite these challenges, there is interest to engage as

several participants shared their rewarding experiences

from physical activity When talking about physical

activ-ity, participants alluded to a ‘gain’, citing how they feel

‘lighter’ and ‘good’ after exercising Participants shared

that initial adoption of physical activity was often in

response to an external cue, including a worrying health

screening result or a recent loss of life Accountability

through exercise programmes or friends or incentives

were cited as facilitators of engaging in physical

activ-ity However, the reasons to sustain behaviour were to

ensure they could maintain their physical appearance,

retain independence and physical mobility to continue

doing the things they enjoy, or continue experiencing the

immediate benefits and enjoyment of certain exercises

“I don’t want to be obese or unhealthy I don’t want

to inject myself all the time or spend my hard-earned

money on doctors or medications So, I exercise

Then, I’ll feel lighter I’ll feel good, fit I’ll be happy,

and I can do a lot of things Through all these

exer-cises, my muscle won’t be so stiff I can do a lot of

things together with my children I can cook for them

and continue to work Then I can go travel if money

permits.” (50s F Chinese)

Many participants also reported that observing

self-improvement by tracking progress acted as positive

feed-back for their self-efficacy, and in return, motivated them

to exercise further or longer Participants who exercise

regularly also pointed out that exercise is a more

indi-vidual activity, and therefore it is not affected like healthy

eating by its social context

One day you cycle down a road, you see some things

and buildings Then the next time, you motivate

yourself to cycle further It’s with running also – in

my mind, I will motivate myself to jog slowly And

then now I can run to this place, to that place, and

then further Then slowly, I can run back It moti-vates me So every time, you look for a new goal to achieve I can go somewhere further, you know? (40s,

F, Chinese)

Discussion

The study findings highlight the importance of under-standing the social and cultural contexts of T2D risk in the development of effective interventions among adults who have elevated risk yet do not engage in preven-tion behaviours The findings explained the dissonance between knowledge and practice of T2D behaviours In the study, dietary change was generally perceived nega-tively due to the hedonistic approach to food and its strong association with Singapore food culture and social interactions Further, access to healthy food required more effort to prepare and costs more than unhealthy options Visible impacts from healthy eating, like weight loss, can be small and slow, creating limited observable short-term benefits Time needed for physical activity can also be overshadowed by competing priorities of work and familial commitments However, exercise was per-ceived to have short-term gains related to wellness and physical performance These gains contribute to the posi-tive feedback loop and enforce self-efficacy of behaviour, making one more confident and motivated to practice Hence, the differential view of loss and gain associated with healthy eating and exercise could influence the var-ied sustainability of the respective behaviours

Our findings align with a local study that showed high awareness of diabetes and perceived efficacy of preventa-tive behaviours and shed some light on why actual uptake

of these behaviours may be low despite the high knowl-edge [11] Perceived severity of diabetes comes from the downstream complications of the later stages of T2D, which seem to be distant for those without T2D With an incomplete understanding of diabetes, the lack of sugar consumption creates a lower perceived susceptibility to T2D The perception of T2D developing slowly and being influenced by personal experiences was also reported in

a similar study in the US [18] Temporal discounting of the future reduces the benefits of preventative behaviours especially given the short-term costs [19], and optimism bias can also lower the perceived risk of diabetes [20] These give rise to lower levels of motivation for behav-iour change and the lack of urgency to act now

Economic utility theory, which suggests that people will only change their behaviour if the perceived benefits out-weigh the perceived costs, could explain why some peo-ple might not see adapting healthy eating now to prevent T2D in the future as a worthwhile investment [21] Per-ceived costs of healthy eating overlap with the perPer-ceived

losses of developing diabetes; they are both associated

with an increased cost of time and money Diabetes

pre-vention and management both require dietary changes

related to impaired enjoyment and social interactions

Pleasure derived from food was so important that

indi-viduals looked to various compromises and

justifica-tions to continue eating their favourite foods Conversely,

perceived benefit is weak due to the limited observable

short-term benefits, creating present bias [22] Hence,

when assessing the costs and benefits of healthy eating,

there might be hesitance to pay these ‘costs’ now instead

of waiting until the risk is higher, or even until diagnosed

with T2D

Physical activity, on the other hand, has important

short-term benefits that create a positive feedback loop

The importance of positive feedback in diabetes

preven-tion and management through short-term gains was

deemed particularly important as altering blood glucose

can be discouraging due to a lack of observable results

[23] Though physical activity shares short-term costs like

time and effort with dietary change, it is less subjected

to some of the barriers like impaired social interactions

and pleasure Physical activity is instead seen to

facili-tate social interactions and pleasure Other facilitators

include incentives and tracking progress, which aligns

with the successes of the National Steps Challenge (NSC)

[24] but can be challenging to leverage for healthy eating

Lack of objectivity in food measurement resists an

incen-tive-based framework, but HPB has launched the ‘Eat,

Drink, Shop Healthy Challenge’ that is currently

attempt-ing this However, like NSC, it is likely to fall victim to

compliance and sustainability issues

Translating our findings using the constructs of

Protec-tion MotivaProtec-tion Theory (PMT) can inform strategies to

address the dissonance between knowledge and practice

PMT suggests that threat and coping appraisals influence

the intention of behaviour following an emotion-evoking

stimulus [25, 26] Our findings indicate that both the

threat appraisal and coping appraisal were sub-optimal

among adults without T2D in Singapore Using an

appro-priate risk communication tool to return health

screen-ing results to elicit an emotional and salient response

is an opportunistic time to elevate this threat appraisal

Health care professionals should be vigilant in

appropri-ately framing the consequences of living with diabetes In

efforts to encourage active diabetes management, it was

communicated that diabetes does not prevent a

fulfill-ing life, which may have reduced the perceived severity

of T2D An elevated risk appraisal is associated with an

increased intention for behaviour change due to

height-ened emotional response and perceived severity [27]

To increase coping appraisal, it is important to address

barriers and create positive associations to preventative

behaviour Reducing perceived response cost and increas-ing perceived benefits through observed performance is critical for sustainable behaviour change [28]

A key systematic-level barrier cited was the acces-sibility of healthier food options due to increased cost and inconvenience The implications are likely inequi-table among the different socio-economic groups of the population Health outcome inequities due to the cost

of healthy eating, an example of social determinants

of health, have been demonstrated globally [29–31] Structural interventions are necessary to address health inequity, such as direct health promotion at the point

of sale (e.g., labelling policies on menu boards and food packaging) and food supply interventions to support the “Healthier Hawker Program” [32] Understanding the unique barriers of the different ethnic groups could also address the differentiated risk profiles The tension between internalised expectations of exercise and cultur-ally accepted practices among Muslim women has also been demonstrated among their communities in the UK [33] Further, in-depth exploration of challenges specific

to Singaporean-Malay women has uncovered similar findings to ours [34] Even though Malays and Indians are disproportionately affected by T2D [2 35], there are no population-tailored interventions to address this health disparity For example, providing accessible exer-cise spaces for Muslim women, who are usually Malay or Indian, can promote privacy and inclusivity

When creating positive associations, short-term ben-efits need not be health-focused Highlighting benben-efits associated with well-being can influence motivations for uptake of T2D prevention [36, 37] Moving to non-health but valued aspects of well-being can create sali-ent perceived benefits and leverage pressali-ent bias This

is especially beneficial among those who perceive to have little to no risk of diabetes and do not perceive the need for change [23] For example, the Asian tendency

to put familial and work responsibility above self-care

is reflected in the time-management barrier However, successfully fulfilling these responsibilities contribute

to their quality of life Hence, shifting narratives on how healthy eating and physical activity can facilitate one’s career growth and in taking care of their family not only honour what is important but can also make the per-ceived benefits larger than perper-ceived costs

Shifting narratives is not easy Given the influence on the perception of T2D, media platforms can be an impor-tant channel to consider for such dissemination It is important to tailor the language appropriately to avoid overwhelming amounts of medical jargon Dramatic television series have demonstrated impact in showcas-ing lived experiences of diseases which can shape per-ceptions and attitudes [38] However, with the younger

population, leveraging culturally popular individuals

may be more effective Social media ‘influencers’ have

increased uptake of healthy behaviours by

associat-ing exercise and dietassociat-ing with health and happiness [39]

These channels can be particularly useful in

demonstrat-ing how healthier choices can be enjoyed and integrated

into social aspects to reduce the perceived costs of

die-tary change

Limitations

We did not collect data from other stakeholders, such

as healthcare providers, to understand their

perspec-tives Primary care physicians could provide insights on

their conversations with at-risk patients to gain insight

on common challenges and success stories This could

have been particularly beneficial as it addressed potential

response bias Since health-seeking individuals are more

likely to participate in health research, we might not have

captured the experiences of a particularly important

group of population Our recruitment strategy was

reli-ant on social media and bulletin boards in primary care

clinics which might have left out perspectives of

individ-uals who did not engage with either of those platforms

Providing a voucher as compensation for their time could

have added an incentive to share the study details with

their families and peers making our study prone to

selec-tion bias We attempted to minimise this by recruiting

participants across all socio-economic groups While all

the interviewers grew up in the region and were familiar

with the local jargon and speaking the same language as

the participants provided a level of comfort, they were all

female Having male interviewers might have made some

participants more comfortable sharing certain topics

Conclusions

Lay beliefs and perceptions of T2D risk are contextual,

shaped by social representations of the disease conditions

and cultural practices relating to T2D prevention T2D

was perceived as a disease that slowly progressed and

caused inconvenience and disability but did not lead to

death Motivation to practice healthy eating was

subop-timal Participants believed that it would have the same

‘costs’ as the perceived loss of pleasure from enjoying

food in social interactions, narrated as the essence of the

local culture and belonged identity Cue to initiate

behav-iour needs to be emotionally driven in collective contexts

while sustaining behaviour is through individual positive

feedback from observed short-term benefits Future T2D

prevention interventions need to emphasise the roles

of lay beliefs and perceptions of the disease in practices

for adults who are knowledgeable but undetermined for

prevention

Abbreviations

T2D: Type 2 Diabetes; HPB: Health Promotion Board; NSC: National Steps Chal-lenge; PMT: Protection Motivation Theory.

Supplementary Information

The online version contains supplementary material available at https:// doi org/ 10 1186/ s12889- 022- 14020-z

Additional file 1 Interview Topic Guide.

Acknowledgements

The authors thank the participants in this research for their time We thank Ho Cheng En, Tan Sok Teng, and Aysha Farwin who conducted in-depth inter-views in Chinese, Tamil, and Malay.

Authors’ contributions

JH and HY conceived the design for the current research study and the pre-liminary coding JH conducted the majority of the data collection All authors were involved in data analysis JH wrote the first draft of the manuscript under the supervision of HY, who later revised and made the final draft All authors commented on the final draft and approved the version of the manuscript to

be published.

Funding

This work was supported by National Medical Research Council, under the Open Fund Large Collaborative Grant The content is solely the responsibil-ity of the authors and does not necessarily represent the official views of the Council.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations Ethics approval and consent to participate

Ethical approval was obtained by the Institutional Review Board of the National University of Singapore (NUS-IRB-2020–267) Informed consent was obtained from all study participants and/or their legal guardian(s).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1 Saw Swee Hock School of Public Health, National University of Singapore, and National University Health System, Singapore, Singapore 2 Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore 3 Division of Endo-crinology, University Medicine Cluster, National University Hospital, Singapore, Singapore

Received: 18 January 2022 Accepted: 17 August 2022

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